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BASIC PATHOLOGIC REACTIONS

of THE SKIN

Mudjiwijono HE Department of Anatomic Pathology Faculty of Medicine Brawijaya University

REACTIVE UNITS of the SKIN


1. SUPERFICIAL REACTIVE UNIT * EPIDERMIS * THE JUNCTION ZONE * THE PAPILLARY BODY - the subjacent loose connective tissue

- capillary network - superficial venular plexus


2. THE RETICULAR LAYER

- connective tissue - vascular plexus - hair follicles and glands


3. THE SUBCUTANEOUS TISSUE

- septal - lobular

DISTURBANCES of SUPERFICIAL REACTIVE UNIT


1. DISTURBANCES of EPIDERMIS * DISTURBANCES of EPIDERMAL CELL KINETICS * DISTURBANCES of EPIDERMAL CELL DIFFERENTIATION * DISTURBANCES of EPIDERMAL COHESION 2. DISTURBANCES of DERMAL-EPIDERMAL COHESION 3. PATHOLOGIC REACTIONS of the ENTIRE SUPERFICIAL REACTIVE UNIT

DISTURBANCES of EPIDERMAL CELL KINETICS


1. CELL PROLIFERATION THE GENERATIVE CELL PLATE >

EPIDERMAL CELL POPULATION


ELONGATION of the RETE RIDGES ( ACANTHOSIS ) 2. CELL PROLIFERATION THE GENERATIVE CELL VOLUME < FLATENING of the RETE RIDGES EPIDERMIS BECOME THINNER ( ATROPHY ) 3. PRODUCTION of CORNEOCYTES THICKENING of the STRATUM } DESQUAMATION of CORNEOCYTES CORNEUM

( HYPERKERATOSIS )

DISTURBANCES of EPIDERMAL CELL DIFFERENTIATION


1. INCOMPLETE DIFFERENTIATION in POSTMITOTIC GERMINATIVE
CELLS / REDUCED TRANSIT TIME / DIRECT CELLULAR INJURY RETENTION of PYKNOTIC NUCLEI in STRATUM CORNEUM ( PARAKERATOSIS ) 2. DIRECT PHYSICAL / CHEMICAL / BIOLOGICAL INJURY PREMATURE CORNIFICATION of INDIFIDUAL CELLS ( DYSKERATOSIS / apoptosis )

DISTURBANCES of EPIDERMAL COHESION


1. INFLUX of TISSUE FLUID INTO THE EPIDERMIS SPONGIOSIS EDEMA INDIVIDUAL CELLS RUPTURE and LIZE SPONGIOTIC VESICLES LARGE BLISTER 2. MIGRATION of LEUKOCYTES SPONGIFORM PUSTULE 3. TRAUMA DISSOLUTION of CELLS (CYTOLYSIS) BLISTERS

4. SEPARATION of the INTERDESMOSOMAL REGIONS


SPLITTING and DISAPPEARANCE of DESMOSOMES ( ACANTHOLYSIS ) INFLUX of FLUID from THE DERMIS SUPRABASAL / MID EPIDERMAL / SUBCORNEAL CAVITATION

Acanthosis

Hyperkeratosis

Parakeratosis

dyskeratosis and acantholysis

Spongiform vesicle

Acantholysis

Pemphigus Vulgaris

Pemphigus vulgaris

Pemphigus Vulgaris

Herpes simplex infection

DISTURBANCES of DERMAL-EPIDERMAL COHESION


DESTRUCTION of the JUNCTION ZONE SUBEPIDERMAL BLISTER

( by Light Microscope )
PATHOGENESIS : - Auto-Ab Specific Ag on the CYTOMEMBRANE of BASAL CELLS (JUNCTIONAL BLISTERING) - INFLAMMATORY PROCESS on the ENTIRE JUNCTION ZONE ( Auto-Ab type VII COLLAGEN / PHYSICAL / CHEMICAL CHANGES ) SUBEPIDERMAL / DERMOLYTIC BLISTERING

Bullous Pemphigoid

Bullous Pemphigoid

Epidermolysis bullosa

Epidermolysis bullosa

PATHOLOGIC REACTIONS of the ENTIRE

SRU

MOST PATHOLOGIC REACTIONS of the SUPERFICIAL SKIN INVOLVE > 1 SUB UNITS of the SRU JOINTLY (incld. Papillary body) CLINICAL PICTURES DEPEND ON THE PROMINENCE of INVOLVEMENT * A FEW SKIN DISEASES ARE EXAMPLES :

contact dermatitis psoriasis interface dermatitis erythema multiforme lupus erythematosus lichen planus dermatitis herpetiformis

Contact dermatitis

Lupus erythematosus

Lichen planus

Dermatitis herpetiformis

Dermatitis herpetiformis

Erythema multiforme

Erythema multiforme

THE DERMIS
Principally, two reaction patterns occur : (1) acute inflammatory processes in which the epidermis and junctional zone are often involved together with the vascular system (2) chronic processes that often remain confined to the perivascular compartment.

INFLAMMATION, CHARACTERIZED BY : - vascular dilatation - increased permeability - edema - reduction of intravascular blood flow - accumulation of red blood cells in the capillary loops - cellular infiltration of the perivascular tissue - activation of perivascular histiocytic and connective tissue cells

Macroscopic : erythematous, urticarial, or infiltrative lesions (wheals, redness, papules).

Manifestation of the release of mediators from IgE-laden mast cells :


- vasodilatation - edema of the papillary body - infiltrate of leukocytes and histiocytic around the superficial venules

CHRONIC INFLAMMATORY REACTION : * Lymphocytic infiltrates in close association with the vascular walls. * Histiocytic elements partly laden with phagocytosed material * Secondary changes due to the interruption of the vascular flow : - necrosis, blistering, ulceration.

Urticaria

Urticaria

Drug eruption

Necrotizing vasculitis

LYMPHOCYTIC INFILTRATES * Formed in : - inflammatory - proliferative conditions - benign - malignant process. * The analysis of such infiltrates : - cytomorphology - distribution pattern : perivascular, diffuse, or nodular - histochemical properties - immunologic markers * Extension of the infiltrate into the fat is often a sign of a malignant lymphoma

Angiolymphoid hyperplasia

Mucinosis in lupus erythematosus

POLYMORPHONUCLEAR LEUKOCYTIC INFILTRATES Neutrophils are the classic inflammatory cells of acute bacterial infections, sometimes in the absence of a bacterial cause such as in pyoderma gangrenosum, massive neutrophilic infiltration leads to sterile abscesses, breakdown of the tissue, and ulceration.

GRANULOMATOUS REACTIONS * The proliferation and focal aggregation of histiocytic cells be termed a granuloma. * When such cells are closely clustered they resemble epithelial tissue, hence the designation epithelioid cells. * Granulomatous reactions of the skin comprise a large spectrum of histopathologic features : - Palisading granulomas surround necrobiotic areas of the connective tissue with histiocytes in radial alignment , such as : Granuloma annulare, necrobiosis lipoidica, rheumatoid nodules, and the juxtaarticular nodules of syphilis. - Necrosis : Fibrinoid necrosis in sarcoidosis, Caseation in tuberculosis

Necrobiotic Granuloma

Rheumatoid Nodule

Granuloma annulare

Sarcoidal Granuloma

Sarcoidal granuloma

FIBROUS DERMIS and EXTRACELLULAR MATRIX Thickening of the dermis not only results from an increase of its fibrous components but is also caused by the fibrosis of the superficial layers of the subcutaneous fat that follows lymphocytic infiltration and a histiocytic reaction. The concomitant involvement of the epidermis includes hydropic degeneration of basal cells, atrophy, and hyperkeratosis. Changes in the junctional zone may occasionally lead to a separation of the epidermis from the dermis and thus to blister formation. Changes in the extracellular matrix may occur in practically all pathologic processes of an inflammatory or a neoplastic nature. Pronounced accumulation of glycosaminoglycans occurs in inflammatory conditions.

Scleroderma

SUBCUTANEOUS FAT * Inflammation : in the adipose tissue / septa * Histopathologic manifestations : - Involve small-vessel, usually manifested locally, involving the neighboring fat lobules. - Destruction / occlusion of a larger vessel influence the entire tissue segment supplied or drained by this vessel, possibly including the overlying dermis. - Destruction of fat (traumatic / inflammatory ) fatty acids release (strong inflammatory stimuli), attracting neutrophils and scavenger (histiocytes and macrophages) phagocytosis of destroyed fat lipogranuloma - Septal : massive edema, infiltration of inflammatory cells, and a histiocytic reaction. - Fibrosis

Erythema nodosum

Nodular vasculitis

Injection granuloma

Thank you for your attention